Welcome!

This is a long form, but please don't be intimidated - most sections are not compulsory. However, by filling it out comprehensively you are helping your clinician to understand your situation, and you are likely to end up with more time in your appointment to discuss issues of importance to you. If you need to step away from the form, or you are putting in a lot of time to make it comprehensive, please consider using the 'Save and complete later' link at the bottom of the page.

PLEASE NOTE:

Dr Foote is not available for private work, or ACC treatment. He is available for ACC assessments only.

Age this month

Contact details

First name *

Last name *

Date of birth *

Age *

NHI number

Mobile number *

Home number

Email *

Street address

City

Postcode

Gender *

MaleFemaleOther

Gender details

Ethnicity

What is your occupation?

How long have you been in this kind of work?

Relationship status

SingleIn a relationship Widow/widowed

How long since you were in a relationship?

How long was your last relationship?

Years together

Partner's first name

Partner's age

Partner's occupation

Do you have children?

NoYes

Child's gender

Child's age

Living situation

Presenting issues

Notes on presenting issues / why you are seeking an assessment

Recently, my:

Has been:

Mental health history

Age at prior issues

Provider

Details

Prior medication

Started

Duration taken

Max dose

Side effects

My thoughts

Common psychiatric medications include antidepressant medications like fluoxetine, sertraline, citalopram, paroxetine, escitalopram, amitriptyline, nortriptyline, mirtazapine, venlafaxine, duloxetine, buspirone, and bupropion; antipsychotic medications like quetiapine, risperidone, aripiprazole, olanzapine, amisulpride, ziprasidone, zuclopenthixol, and clozapine; anti-convulsant / mood stabilising medications like lithium, sodium valproate (Epilim), lamotrigine (Lamictal), and carbamazepine (Tegretol); benzodiazepine medications like lorazepam, clonazepam, diazepam, triazolam (Halcion), and oxazepam; and other medications like melatonin, zopiclone, and benztropine.

Treatment comments

Medical history

Medical problem

Had since

Effect on my life

Current medications

Name

Dose and freq

Started

Reason taken

Side effects

Allergies and adverse drug reactions

Medication

Adverse reaction

Substance use

Have you ever had or received treatment for substance use problems, or used substances heavily?

Do you have any concerns about your substance use?

GP details

General practitioner

Practice name

GP practice email

Insurance details

Insurer

Policy number

Emergency contact details

Emergency contact

Relationship to you

Contact number

Appointment details

Have you already been offered a Northland Psychiatry appointment, or completed your appointment? *

Yes, I haveNo, please offer me an appointment slot

Who will be paying for your appointment? *

ACC or another third-party payer e.g. Gallagher BassettSouthern Cross or other insurancePaying privately (self or other party)

There will be no additional fees payable if your third-party provider (ACC or other) has raised a purchase order for your Northland Psychiatry assessment.

Please be sure to complete the insurance details above. Depending on the details of your insurance plan, there may be a shortfall to be made up. In that case, we will send you an invoice after your appointment.

If you are seeing Dr Foote, your comprehensive initial assessment will take up to ninety minutes, and may take place via Zoom if you live out of the Northland area or if Dr Foote is travelling. After a thorough and sensitive exploration of presenting issues, psychiatric history, medical history, family history, lifestyle, life experiences, and personality, Dr Foote will discuss with you the diagnosis (if any) and how your experiences can be understood medically and/or psychologically (for more about the unique skills of a psychiatrist, please see www.northlandpsychiatry.co.nz/what-is-a-psychiatrist/). You can then discuss options including medications, psychotherapy, other therapies, and agencies which may be of assistance.

Dr Foote will prepare a 2-3 page report for you and/or your GP in the week following your meeting. The cost for an initial assessment is $850 including GST. You can pay by internet banking at least two days in advance to ASB 123135015061600, or by cash in person (we do not have EFTPOS). If you need a special type of assessment or report (e.g. for court) please advise immediately as the cost may change and we may have to reschedule.

Comments or questions

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Please email me a copy of this form

YesNo

Confirmation

Signature *

Clear

By signing, I confirm that I am the person above; the accuracy of this information; my consent to pay any fees; my consent for Northland Psychiatry to seek relevant health information including blood test results, medication details, and other documentation deemed necessary by Northland Psychiatry clinicians for your safe and appropriate treatment; and my acknowledgement that Northland Psychiatry staff operate according to New Zealand's Health Information Privacy Code 2020 (https://www.privacy.org.nz/privacy-act-2020/codes-of-practice/hipc2020/). Northland Psychiatry will maintain the confidentiality of your information, communicating with other health professionals as necessary. In case of significant and immediate concern about your safety or that of others around you, if possible we will discuss with you our concerns and agree on a way forward - in extreme situations, it may be necessary to make limited disclosures to others even if you do not agree. This is uncommon, but important for you to understand in seeking support from Northland Psychiatry.

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